Nokea
A client diagnosed with pneumonia is experiencing shortness of breath, chest pain, and orthopnea. The chest x-ray reveals a very large right pleural effusion. Which intervention should the nurse anticipate for this client?
- A. Endotracheal intubation
- B. Paracentesis
- C. Thoracentesis
- D. Ventilation-perfusion scan
Correct Answer: C
Rationale: Thoracentesis removes fluid from the pleural space, relieving pressure on the lung and improving breathing in a large pleural effusion.
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The nurse is caring for assigned clients. Which of the following clients should the nurse check first?
- A. client who had a cholecystectomy and is reporting incisional pain as 5 on a scale of 1-10
- B. client who had an open reduction of the right femur and is reporting nausea
- C. client with type 1 diabetes mellitus and a blood glucose level of 55 mg/dL (3.1 mmol/L)
- D. client with type 2 diabetes mellitus and a blood glucose level of 250 mg/dL (13.9 mmol/L)
Correct Answer: C
Rationale: A blood glucose level of 55 mg/dL indicates severe hypoglycemia, a life-threatening condition requiring immediate intervention to prevent seizures or coma.
An infant is to be admitted with severe diarrhea. Which room assignment is best for this infant?
- A. A private room
- B. A room close to the nurse's station
- C. A room with a 2-year-old child who has a broken leg
- D. A room with another infant with severe diarrhea
Correct Answer: A
Rationale: A private room prevents transmission of infectious diarrhea to others. Proximity to the station, sharing with a non-infectious patient, or another diarrheal infant increases risks.
The practical nurse is collecting data on a client receiving methotrexate to treat rheumatoid arthritis. Which finding associated with this drug is most important for the nurse to report to the registered nurse?
- A. Hair loss
- B. Nausea
- C. Petechiae
- D. Stomatitis
Correct Answer: C
Rationale: Petechiae indicate thrombocytopenia, a serious adverse effect of methotrexate, risking bleeding and requiring immediate reporting for dose adjustment or discontinuation.
The nurse is calculating a client's intake and output for the shift. How many mL should the nurse record as the client's net fluid balance? Record your answer using a whole number.
Correct Answer: 655 mL
Rationale: 1. Intake:
Oral: 180 + 240 + 360 = 780 mL
IV: 1000 + 75 + 250 = 1325 mL
Total Intake = 780 + 1325 = 2105 mL
2. Output:
Stool: 150 mL
Urine: 1300 mL
Total Output = 1450 mL
3. Net Balance:
2105 − 1450 = 655 mL net positive balance
The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to
- A. Excessive fetal weight
- B. Low blood sugar levels
- C. Depletion of subcutaneous fat
- D. Progressive placental insufficiency
Correct Answer: D
Rationale: The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may be related to hypoxia.